NCLEX-RN
NCLEX Psychosocial Integrity Questions
1. Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?
- A. ''Tell me more about being Joan of Arc.''
- B. 'We both know that you're not Joan of Arc.''
- C. ''It seems like the world is a pretty scary place for you.''
- D. 'You're safe here, because we won't let you be burned.''
Correct answer: C
Rationale: The nurse would say, ''It seems like the world is a pretty scary place for you.'' This response allows the nurse to understand the symbolism, reflect on and acknowledge the client's feelings, and help preserve the client's integrity. The statement, ''Tell me more about being Joan of Arc,'' validates the client's delusion and does not test reality. The statement, ''We both know that you're not Joan of Arc,'' rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement, ''You're safe here, because we won't let you be burned,'' is false reassurance; the nurse is agreeing with the client's false perceptions of reality, which is nontherapeutic.
2. The client has a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?
- A. Mastery of colostomy care techniques
- B. Readiness to accept an altered body function
- C. Awareness of community resources available
- D. Understanding necessary dietary modifications
Correct answer: B
Rationale: The most crucial client outcome for successful adjustment to a new colostomy is the readiness to accept an altered body function. Acceptance of changes in body image and function is essential to facilitate mastery of colostomy care techniques and optimal utilization of community resources. Without readiness to accept the altered body function, the client may not be open to learning and adopting necessary changes, hindering the achievement of long-term goals. Understanding dietary modifications, while important, is secondary to the fundamental acceptance of the altered body function in the process of adjusting to a new colostomy.
3. Which clinical findings indicate positive signs and symptoms of schizophrenia?
- A. Withdrawal, poverty of speech, inattentiveness
- B. Flat affect, decreased spontaneity, asocial behavior
- C. Hypomania, labile mood swings, episodes of euphoria
- D. Bizarre behavior, auditory hallucinations, loose associations
Correct answer: D
Rationale: The correct answer is bizarre behavior, auditory hallucinations, and loose associations. These are positive symptoms of schizophrenia, reflecting a distortion or excess of normal function. Withdrawal, poverty of speech, inattentiveness, flat affect, decreased spontaneity, and asocial behavior are negative symptoms linked to schizophrenia, indicating a diminution or absence of normal function. Hypomania, labile mood swings, and episodes of euphoria are more characteristic of bipolar disorder, rather than schizophrenia.
4. A client with invasive carcinoma of the bladder is scheduled for a cystectomy and an ileal conduit. The client expresses worries about the possibility of offensive odors associated with the urinary diversion. How would the nurse respond?
- A. ''Tell me more about your concerns.''
- B. ''Products are available to address this issue.''
- C. ''This is a valid concern, and we can discuss ways to manage it.''
- D. ''Many individuals who undergo this procedure have similar worries.''
Correct answer: A
Rationale: The response ''Tell me more about your concerns'' is open-ended, encouraging the client to express their worries freely. This approach fosters communication and shows empathy. Option B acknowledges the concern and offers a solution, demonstrating support and understanding. Option C validates the client's worry and suggests collaboration in finding solutions. Option D normalizes the concern but may not address the client's specific worries, making it less therapeutic than the other options. Overall, actively listening to the client's concerns and offering support are essential in providing holistic care.
5. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?
- A. Establish trust
- B. Increase feelings of self-worth
- C. Solidify sense of identity
- D. Improve ability to socialize
Correct answer: A
Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.
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